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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. { Job Address 191 It V45%Rk•�ta.,gs /tf A�r � j 'Ci J Lot Size PM 4ea— Owner's Name Address 16a99'C1 �. kA, _ Phone ®a74-1�3 J) ,�7 C 4 ,Contractor " w ///%'Sr Addressls e)r o�o� �^ License No. l"r 2� Phone TYPE OF WELL/PUMP: NEW WELL WELL EPLACEMENT ❑ DESTRUCTION ❑PUMP INSTALLATION SYSTEM REPAIR ❑ OT ER ❑ DISTANCE TO NEAREST: SEPTIC TANK / .3- SEWER LINES AZC 1t DISPOSAL FLD�� PROP. LINE �0� FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Exca tion f Dia. of Well Casing Domestic/Private X Gravel Pack ❑ Tracy Type of Casing Specifications ❑ PUblic ❑ OtfPer ❑ Delta Depth of Grout Seal �' T © Irrigation Type of Grout �� L"c'' " ��pprox. Depth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501). TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t Installation will serve Resid1ence: Ciam;ercial available within 200 feet.) _ Other i Number of living units: Number of bedrooms Ch�racter of soil to a-depth of r3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PK G.1TREATMENT PLT. ❑ 1� Method of Disposal Distance to nearest:7'-' Well .Foundation Property Line I LEACkNG LINE ❑ No. & Length of lines` Total length/size FILTER BED ❑ Distance to nearest: r Well Foundation -d� Property Line �k SEEPAGE PITS ❑ Depth. a ",,-Size Number SUMPS ❑ Distance to rest: Well Foundation Property'Lin!e DISPOSAL PONDS ❑ i I hereby certify that 1 have prepared_this application and that the work will be done in accordance with Sanoaquin county ordinances, state laws, and rules and regulations of the San Joaquin ocal Health District. Home owner or licensed agent's signature'certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring.or sub-contracting signature certifies the following: "I certify that in the;performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." a The appli /must��caaall for all re ed i ctions. Complete drawing on reverse side. f`Ii I /vKi"r4-- ] 4 Signe, � ��- �Z� Title: JJJ IOate:' II /y��/ FOR DEPARTMENT USE ONLY Applidation Accepted by P U i Date Pit or'Grout Ins -� f1 Area t Inspection by + Date v ;�•, A\ Q _ Addidi i�6naltommerlts:, 1, � 1 "-�"'S�R�4�6-fi78i.� •-'� p'Lodi" 369-36:.H: Manteca-821.71104F ❑ Tracy 835-6385 "- Applicant- Return all copies to: Environ Intal-HealtK P,ermhf9eyq'Y:es 1801E. Hazelton Ave., P.O. Box 2009 tk. C FEE AMOUNT DUE AMOUNT REMITTED INFO �} �] /CASH RECEIVED 6Y DATE �j PERMI/T NO. + EH 1426(REV"tie 51 �(/. dam /�. d^-e� l '-1`S A / �'7